26.1.12

Clinical- Orthopedics examination


General Orthopedic Examination Scheme

Introduce yourself
Exposure: to joint above
Standing
1-    Look From back,  From side, From Front    
·          Skin → Scars, sinuses                   ·   SCT → swelling                                                  
·          Muscles → Wasting or Spasm
·          Bones     Deformity                    
2-         Walk (Gait)  امشى لحد الباب وارجع 
·           Normal (most propably)
·           Abnormal (Antalgic بيعرج , Trendlenberg بيرقص, Half Shut knife)
3-         Feel  For tenderness
·           Bony landmarks
·           Soft tissue
4-         Move
·           Range → full ….-….) / limited (….-….)
·           Pain → painful/ painless
5-         Special Tests
6-         Measure
Supine
1-    Look       
2-       Feel  For tenderness
·           Bony landmarks
·           Soft tissue
3-      Move
·           Range → full ….-….) / limited (….-….)
·           Pain → painful/ painless
4-      Special Tests
5-      Measure
Prone   مفيش وقت
1-        Look       
1-                 Feel  For tenderness
·           Bony landmarks
·           Soft tissue
2-            Move
·           Range → full ….-….) / limited (….-….)
·           Pain → painful/ painless
I would like to finish my examination by:
1-         Examination of joint above & joint below.
2-         Examination of neurovascular status of both LLs.
3-         Ask for X-ray (Bilat. & 2 views).
Investigations
Lab:  ESR, CRP, ASOT, Rheumatoid profile, HLA-B27 (for ankylosing spondyolitis)
X-ray: plain X-ray bilat. & 2 views at least
CT: If suspect fracture (better 3D CT) 
MRI: If suspect pathology
   TTT
Conservative ttt: bed rest, analgesic (NSAIDs), lifestyle modification (wt.loss), physioth.
Surgery: if failed conservative ttt inform of ……..
                          -after general assessment for fitness to surgery

N.B. urgent surgery may be needed (e.g, in dislocations, foot drop, cauda equine lesion)


Lumbar Spine Examination

Introduce yourself
Exposure: naked except underware
Standing
1-    Look
                       From back     
·          Skin → Scars, sinuses                   ·   SCT → swelling                                                               Muscles → - Erector spinae spasm (Rt/ Lt/ Bilat.) (usually opposite to side disc)
·          Muscles → Erectoe spinae spasm   - LLs muscles (check later by measurement)
·           Bones   → - Leveling of iliac crest → Leveled/ Pelvic tilt toward (Rt/Lt)
                               - Soliosis toward (Rt/Lt) (keep n. away from n.root)
                       From side
                           ·           Bones: → Lumbar lordosis → N/ flattened, N Dorsal Kyphosis
7-         Walk (Gait)  امشى لحد الباب وارجع 
·           Normal (most propably)
OR  ·           Half-shut knife
OR  ·           High steppage (foot drop) (rare & emergency)
8-         Feel  
·           Erector spinae spasm
·           Spine segment tenderness at level of …… (iliac crests = L4)
             Iliac crests, PSIS, Lumbo-sacral junction
9-         Move
·           Forward flexion → range & Pain (N= 5cm from floor or touch toes)
·           Extension → range & Pain (N= 10-30 degrees)
·           Lateral flexion → range & Pain (N=30 degrees or touching knee)
·           Rotation (while sitting to fix pelvis) → range & Pain (N=  45 degrees) (Th.V.)



Supine
5-    Tests
1-   Straight Leg Raising test (SLR)1  4 Parts    الوجع فين
         passive SLR → +ve & limited at …. Degrees / –ve (N= 80°, <60° → Positive)                                            
         10 degree below and Sciatic stretch test 2→ +ve or –ve
          Hip internal & external rotation 3 (at 90-90 position) → range & pain
          Sacroiliac joint strain (FABER test = Flex. + Abduction + Ext.Rot.)
               (figure of 4 position, hand on knee & hand on iliac crest) → +ve / -ve
  

 1 SLR: Elevate leg to 90 o  & If pain < 80o ask about site (below knee → +ve & Above knee → -ve)
2   Sciatic stretch test: After SLR, 10° below to relieve pain + dorsiflexion of the foot → pain & Patient flexes his extended knee to relieve the pain
3  Hip rotation: hip 90 o - knee 90o, hand on knee & other moves leg (inside → ext. rot.) (outside → int.rot.)

2-    Rapid Neurological examination
·          Sensation (Dermatomes) close eyes, compare both sides & ask
                    L1 = below skin crease
                    L2 = upper thigh
                    L3 = lower thigh
                    L4 = inner side of leg
                    L5 = outer side of leg →1st dorsal web (autonomus area of L5)
                    S1 = plantar foot
                    → there is hypothesia on segment… (Rt /Lt) side or both equal
·          Power (Myotomes) against resistance & compare both sides
                     L2 = hip flexion
                     L3 = knee extension
                     L4 = ankle dorsiflexion
                     L5 = big toe dorsiflexion
                     S1 = ankle plantar flexion        
                  → there is weakness on segment… (Rt/Lt) side or both good power

·          Reflexes   preserved or lost & compare both sides
                     → Knee reflex (L2,3,4) look at quadriceps preserved or lost
                     → Ankle reflex   (S1)    look at calf ms       → preserved or lost




Prone   مفيش وقت
·      Femoral stretch test (L2,3,4 root) flex knee & extend hip
           → pain infront thigh = +ve =high disc prolapse

I would like to finish my examination by:
1-         Examination of joint above (dorsal & cervical spine) & joint below (hip).
2-            Examination of peripheral pulsation (to exclude vascular claudication).
3-         ask for X-ray.
4-         Examination of abdomen (to exclude abdominal causes of back pain).
5-         Exclude CAUDA EQUINA by:
                     ONE question → sphincter function (retention early & incontinence later)
                                TWO tests      → sphincter tone (S2)
                                                       → saddle area sensation (S2,3,4)


Hip Joint Examination

Introduce yourself
Exposure:  naked except underware

Standing
1-    Look
                 From back     
·        Skin  → Scars, sinuses                  ·   SCT → swelling                                                                      Muscles → Erector spinae wasting or spasm
·        Muscles → Gluteal ms wasting (lost buttock crease)                          
·        Bones → - Leveling of iliac crest → Leveled/ Pelvic tilt toward (Rt/Lt)
                    - Soliosis toward (Rt/Lt) (Compensatory & opposite to pelvic tilt)
             (Scoliosis with pelvic tilt is compensatory to adduction deformity)
                 From side
·         Skin  → Scars, sinuses                  ·   SCT → swelling
·         Bones Lumbar lordosis →N/ Exaggerated (compensatory to FFD), dorsal kyphosis.
From front 
·         Skin  → Scars, sinuses                  ·   SCT → swelling
·         Trendlenberg test                  
2-       Tests
           Trendelenburg test (S.S.S)1  → -ve/  +ve = abductor deformity   اقف على رجلك ال.....
3-       Walk (Gait)     امشى لحد الباب وارجع according to Trendlenberg test
If Trendlenberg test +ve → Trendlenberg gait
If Trendlenberg test  -ve →  Antalgic gait
4-        Feel  (Standing or Supine) 
·         Hip joint (skin crease) → pain= arthritis    
·         Greater trochanter → pain= trochanteric bursitis    

Supine
  Look Confirm       Feel (if not done standing)
5-        Move active then passive (fix pelvis)
·        Thomas test 2 → +ve = fixed flexion deformity or –ve
·        Flexion → range & Pain (N= 0-140 o)
·        Extension (I will test later in prone) → range & Pain (N= 0-10 o) (skip if FFD)
·        Abduction (fix pelvis by hand & elbow) → range & Pain (N= 0-45 o)
·        Adduction (fix pelvis by hand & elbow) → range & Pain (N= 0-30 o) 
·        Internal rotation (hip 90°& knee 90°- fix knee-leg out) → range & Pain (N= 0-40 o)
·       External rotation (hip 90° & knee 90° -fix knee -leg in) → range & Pain (N= 0-40o)



1 Trendlenberg test: Standing on one leg tests the abductors of supporting leg (gluteus medius & minimus) which pull on
the pelvis → other side to rise (Normal is negative test) [SSS= sound site sag]
2 Tomas test: left hand behind back (to feel flattening of hyperlordosis) flex hip to abdomen & notice flexion of other hip (>10o → +ve)


6-        Measure   (square the patient with pelvis 90 degrees to long body axis)
·      Apparent length (from Xiphisternum to Med. maleollus)→ No/ shortening on (Rt/Lt) side of …. cm  → If no true shortening = adduction deformity
·       True Length (from ASIS to Medial maleollus)→ No/ shortening on (Rt/Lt) side of … cm 
                                      = shortening of femur or tibia
·       (if true shortening) Do rough test (Knee 90o& look from side)→ femoral or tibial
·       (if femoral shortening) measure Supratrochanteric length (from greater trochanter to point same line opposite ASIS)  → supra-trochanteric or infra-trochanteric

  
I would like to finish my examination by:
1-         Examination of joint above (lumbar spine) & joint below (knee).
2-         Examination of neurovascular state of both LLs.
3-         Ask for X-ray

  

         
                        























Knee Joint Examination

Introduce yourself
Exposure:  Both Knees / Examine both knees (mirror image)

Standing
1-    Look
 From front     
·          Skin → Scars, sinuses                   ·   SCT → swelling                                           
·          Muscles → Quadriceps muscle wasting                          
·           Bones →  Genu Varus , Genu valgum
From side
·          Skin → Scars, sinuses                   ·   SCT → swelling
·          Bones →  Genu recurvatum , Flexion deformity
From back (popliteal fossa)
·          Skin → Scars, sinuses                   ·   SCT → swelling (+/-) pulsatile    
2-    Walk (Gait) امشى لحد الباب وارجع
·    Normal        
OR  ·    Antalgic    

Supine                       
3-    Feel     
·         Tenderness (Bony Land Marks & soft tissue):
→ quadriceps ms, quadriceps tendon, patella (patellar grinding test in 2 directions), patellar tendon, tibial tuberosity
→ med. femoral condyle, med.tibial condyle, lat. femoral condyle, lat. Tibial condyle.
→ med. collateral lig., lat. Collateral lig. → head of fibula  
           
·          Effusion:    Start by     Patellar tap test (moderate effusion)
if patellar tap –ve → Fluid shift test [Stroke test] (small effusion )
if patellar tap +ve → Fluctuation test (large effusion)  
4-     Move
·          Extension (Active then Passive) → range & Pain (N= 0o)
·          Flexion (Active then Passive) → range & Pain (N= 0-135 o) (buttocks to heels 1.5 cm)
5-     Measure Quadriceps Circumference (15 cm above patella) → equal/ wasting on (Rt/Lt) side  





 
6-     Tests  
            Knee stability tests
1- Active Straight Leg Raising test (SLR) → +ve = weak extensor apparatus/ –ve
2- Medial & Lateral Collateral ligaments (at 20°)
  · Stress valgus1 Knee 0°: support leg medial and push on lateral knee medially.
     Stress valgus1 Knee 20°:
          no opening joint= -ve = intact
→ opening joint= +ve → confirm by other side (if bilat.=laxity, unilat.=torn)
  · Stress varus: Knee 0°: support leg lateral and push on medial knee laterally.
     Stress varus  Knee 20°:
           no opening joint= -ve = intact
→ opening joint= +ve → confirm by other side (if bilat.=laxity, unilat.=torn)
3- Anterior & Posterior Cruciate ligaments (at 90° + sit on pt. toes)
· posterior sag test: -ve/ +ve → PCL injury at sagged side (Rt/Lt) 
· Posterior drawer test: push tibia (for PCL)
· Anterior drawer test: pull tibia (for ACL)
· Lachman test   · Pivot shift (Painful- only idea)
Mac Murray test 2 (for medial & lateral menisci) not sure test
· Med. meniscus: maximum flexext. rot with extension  → click or pain = +ve 
· Lat. meniscus: maximum flexint.rot. with extension → click or pain = +ve 

                                     
                
Prone   مفيش وقت
 Back of knee (popliteal fossa) 1- Flexed → Popliteal region 
2- Extended → Palpate for bursa


 I would like to finish my examination by:
1-         Examination of joint above (hip) & joint below (ankle).
2-         Examination of neurovascular state of both LLs.
3-         Ask for X-ray
4-         Examin back of knee (popliteal fossa) 1- Flexed Popliteal region 
2- Extended Palpate for bursa
      


                                              

1 Grasp knee with one hand (heels on lateral side of the knee), grasp lower tibia with the other hand, push the tibia laterally
2 Leg is flexed, loosen hamstring by rotatory mvt, Foot internally/externally rotated, and Hip is adducted, clicks or
pain are felt while leg is smoothly extended. If +ve compare because bilat.= lax & unilat.= inj. meniscus
 



Shoulder examination (rare)
Introduce yourself
Exposure: Expose upper half of body &both shoulders & examine from behind pt.


1-     Look



·          Skin →Scars, sinuses                   ·   SCT → swelling               
·          Muscles → Swelling or Wasting (Deltoid, Supraspinatus, Infraspinatus, Trapezius, Pectoralis)
·          Bone → Deformity (Sterno-clav. j., Clavicle, Acromio-clav. j., winging scapula,).
2-     Feel Bony land marks & soft tissue (for tenderness)
·          Sternoclavicular j., clavicle, +/- coracoid, acromioclavicular, acromion, spine of scapula (if protruding= wasting supra- & infra-spinatus), supraspinatus, infraspinatus, head of humerus, 
                                                     (coracoid is 1.5 inch below lateral end of clavicle in deltopectoral groove)












3-     Move
·         Forward flexion → range & Pain (N=180°)
·         Extension → range & Pain (N=60°)
·        Abduction → range & Pain (N=180°) 
           0-15° = supraspinatus,
15-90° = deltoid (gleno-humeral j. mainly)
90-180° = trapezius, Rhomboides & Levator scapulae (scapulo-thoracic j. mainly)
·        Adduction → (N= blocked by body)
·        Medial (internal) rotation → range & Pain (N=80°) fix elbow at body & forearm inside
·        Lateral (external) rotation → range & Pain (N=80°) fix elbow at body & forearm outside









4-     Muscle strength
·  Pectoralis major ☺”Push your hands in your waist.”   ·  Trapezius ☺“Raise your shoulders.”
·  Serratus Anterior  ☺“Push against the wall.”
5-          Special tests
·        Painful arc (supraspinatus tendonitis)
·        Apprehension test (for recurrent shoulder dislocation) -if asked only
Reduction of Dislocated Shoulder (TEAR)
Traction  - External rotation -  Adduction - Rotation (Internal)




Elbow Examination (very rare)

Introduce yourself
Exposure: Up to shoulder & hand supinated (palms up)

1-        Look
·          Skin → Scars, sinuses                   ·   SCT → swellings (joint or localized olecranon bursa)
·          Muscles ( flexors & extensors forearm) → Wasting
·          Bone → Deformity Cubitus valgus = exaggerated carrying angle (N= 10-15° valgus)
                                            Cubitus varus = decreased carrying angle
                                            Cubitus recurvatum = hyperextension elbow
3-        Feel  TT
·          Temperature
·          Tenderness: over bony prominences & ulnar n.
-  Olecranon bursitis
-  Tennis elbow: pain over common extensor origin (lat. Epicondyle) due to extensor use
                -  Golfer’s elbow: pain over common flexor origin (med. Epicondyle) due to flexor use
4-        Move
·        Flexion→ range & Pain (N= 145 degrees)
·         Extension   → range & Pain (N hyperextension upto 15 degrees)
·         pronation & supination (start at mid-prone position)
5-                 Special tests  (elbow stability tests) (elbow extended because no locking unlike knee)
      ·         Stress valgus test: elbow extended, support wrist and push on lateral elbow medially      
      ·         Stress varus test: elbow extended, support wrist and push on medial elbow laterally
               If opening in med.side → +ve valgus test, lat. Side → +ve varus test

Hand Examination (Rheumatoid or Nerve inj.)

Introduce yourself
Exposure: Up to elbows & hand supinated
1-        Look
·          Skin → Scars (esp, palm & wrist), sinuses       ·   SCT → swellings & nodules(imp)
·          Muscles → Wasting (Dorsal interossei, Thenar, Hypothenar)
·         Bone → Deformity (Ulnar dev. MPJ & compensatory radial dev. wrist 1, MPJ swellings 2, finger drop, hyper-extended finger, Swan-neck 3, Boutonniere deformity 4, Z-thumb 5, Mallet finger 6, Piano-key 7)

2-        Feel  TT
·          Temperature
·          Tenderness: Joints, knuckles, tendons.

3-        Move (wrist, MPJ, PIPJ) Active then Passive (to complete range)
·          Wrist: flexion, extension & circular movement
·          Fingers movements: - Flexion & Extension (at MPJ)  - Abduction & Adduction (acc. to middle finger axis) (Middle finger has abd. on 2 sides & no add.)
·          Thumb movements (hand on table): - Abduction (upward) & Adduction
                                                                     - Flexion & Extension (at IPJ)  & Opposition
·         Tendon: FDS & FDP
4-        Nerve
5-        Special tests  (tests for carpal tunnel syndrome & nerve injury)



Ulnar n. inj.
Median n. inj.

Radial n. inj.

Look

-Claw hand
-Wasted hypothenar eminence
-Wasted interossie (guttered dorsum of hand)
 
-Ape hand (thenar wasting)


-Wrist drop

Sensory
Assessment
(autonomus area of  nerve)

-Loss of sensation of  Little finger



- Loss of sensation of index finger





-Loss of sensation of 1st dorsal interosseus space
 


Motor
Assessment

-Palmar interossie (card test) 9
-Dorsal interossie (spread test) 10
-Adductor pollicis (froment test) 11

-Opponens pollicis 12

 

  
 -Abductor pollicis brevis 13 (hand on table)


 
  + Phallen test 14 & Tinnel test 15 (in carpal tunnel synd.) 
Fix proximal joint then
-Finger ext. at MPJ → Lost
-Wrist ext. → Weak or Lost (acc.to level)
- Finger ext. at PIPJ → preserved extension by lumbricals (supplied by median & ulnar n.)


Level of inj
(If asked only)
- Scar
- Ulnar paradox
- FCU
- med. ½ FDP
- Scar
- FDS
- lat. ½ FDP
- Pronator teres & quadratus
- Scar
- Wrist ext.→ weak in post. Interosseus inj. & Lost in main radial inj.
                                                                                                                                                                   
1 Ulnar deviation of fingers (MPJ) & compensatory radial deviation of Wrist (Zig-Zag mech.) (pathognomonic to rheumatoid hand)
2 MPJ swellings (nodules or subluxation of head metacarpals)
3 Swan-neck: rupture tendon FDS → PIPJ extended & DIPJ flexed by FDP (compens)
4 Boutonniere deformity: rupture central slip of extensor expansion → PIPJ flexed & DIPJ extended by 2 distal slips
5 Z-thumb:  rupture Fl.Poll.longus tendon → MPJ flexed & IPJ extended
6 Mallet finger: rupture extensor tendons → DIPJ flexed & cannot be extended except passively (IPJ normal)
7 Trigger finger (Stenosing tenosynovitis): inflamm.nodule prevent active extension of finger PIPJ & DIPJ(cannot be extended except passively with lag & snap)
8 Piano key sign: subluxation of lower radio-ulnar joint → popup lower ulna
9  Card test: Piece of paper between fingers - PAD
10 Spread test: Prevent pushing of spread fingers - DAP
11 Fromet’s test: Piece of paper between index & thumb & try to catch against resistance → Flex. instead abd, thumb
12 Opponens polices: Oppose patient’s thumb & little finger, ask him to stop you from pulling the fingers apart
13  Abd.poll.br..: Hand on table & Abd. Thumb against resistance
14 Phalen test: flex. Wrist → tingeling & pain
15 Tinnel test: tapping on median n. under flexor retinaculum → tingeling & pain


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